Surgery for Fuchs Dystrophy
Fuchs' dystrophy results in loss of corneal endothelial cells and the surgical treatment for this is the transplantation of healthy endothelial cells to replace the absent or diseased cells. The gold standard of corneal transplantation for Fuchs Dystrophy is an operation called endothelial keratoplasty (DSAEK or DMEK surgery). Mr Angunawela is an expert in DSAEK and DMEK surgery and spent one and a half years training with Professor Donald Tan in Singapore who is the inventor of the Tan Endoglide.
Mr Angunawela is also actively engaged in research that has led to significant improvement in the DSAEK surgical technique and our group at Moorfields was recently awarded the 'Best Paper' award by the American Academy of Ophthalmology and the 'Founders Gold Medal' for the presentation and publication of this work.
DSAEK and DMEK surgery is a highly specialised and technically demanding surgical technique. Even in Europe, only 1 out of 4 corneal surgeons are able to perform this technique. In the recent past, patients with Fuchs' Dystrophy would need to have a full thickness corneal transplant (penetrating keratoplasty) leading to a long recovery period. Penetrating keratoplasty is no longer considered the standard of care for Fuchs Dystrophy.
DSAEK (Descemets stripping automated endothelial keratoplasty) Endothelial Transplantation Surgery
DSAEK surgery is performed through very small incisions that allow the surgeon to gently introduce a thin layer of donor corneal tissue with healthy endothelial cells into the front compartment of the patient's eye. Mr Angunawela uses the Tan Endoglide to do this as this device has been shown to cause the least damage to the donor tissue at the time of insertion. The layer of donor tissue is specially prepared and is only one tenth of a millimetre thick.
Once the new endothelial cell layer is within the eye it is gently floated upwards until it makes contact with the back surface of the patient's cornea. An air bubble is then positioned behind the graft tissue which is then pressed into position. No stitches are used to hold the graft in position. Some air is left in the eye at the end of surgery and the patient is asked to lie flat for at least a hour after surgery so that the air bubble continues to support the new layer of cornea in position.
Surgery can be performed under local or general anaesthesia.
DMEK (Descemets Membrane Endothelial Keratoplasty) endothelial transplants
DMEK is the purest form of endothelial transplant. In this sophisticated surgery the diseased endothelium is removed and replaced with a sheet of pure endothelial cells from a donor. The thickness of the replaced tissue measures just 1/100 of a milimetre. DMEK surgery is performed by just a few surgeons in the UK including Mr Angunawela. The significant advantages of DMEK include faster visual recovery compared to DSAEK and a very low rejection risk. Surgery can be performed under general or local anaesthesia.
The main advantage of DMEK is a rejection rate lower than 1% and faster visual recovery.
Not all patients are suited to have DMEK surgery. Your surgeon will discuss this with you.
DSAEK/DMEK and cataract surgery
As Fuchs dystrophy commonly occurs as patients enter their fifties and sixties some cataract is often present. Conversely Fuchs Dystrophy is often accelerated by cataract surgery and other types of surgery that can lead to earlier corneal failure.
If there is cataract present at the time that DSAEK/DMEK surgery is required, then cataract surgery and DSAEK/DMEK can be combined in the same operation. Mr Angunawela prefers this approach as it means that only one surgery and anaesthetic is required. Mr Angunawela will discuss the best option for you.
Mr Angunawela teaches DSAEK on the highly successful 'Advanced DSAEK surgery' together with Professor Tan at the annual European Corneal Society meeting.